title: Outcomes of surgical aortic valve replacement in moderate risk patients: implications for determination of equipoise in the transcatheter era.
abstract: OBJECTIVE
  To determine the contemporary outcomes of surgical aortic valve replacement (SAVR) in a moderate surgical risk population.
  
  
  METHODS
  We studied 502 consecutive adults who had undergone isolated SAVR from January 2002 to June 2011 for severe aortic valve stenosis with a Society of Thoracic Surgery predicted risk of mortality of 4% to 8%. We included concomitant coronary artery bypass and aortic annular enlargement but not other concomitant procedures. The updated Valve Academic Research Consortium definitions were used, as appropriate.
  
  
  RESULTS
  The median age was 80 years (range, 49-96), 323 (64.3%) had New York Heart Association class III-IV symptoms, and 101 (20.1%) had undergone previous coronary artery bypass grafting. The mean predicted risk of mortality was 5.6%. Concomitant coronary artery bypass grafting was performed in 270 (53.8%). Re-exploration for bleeding occurred in 29 (5.8%), stroke in 9 (1.8%), and vascular complications in 2 (0.4%). In the cohort, 14 early deaths (2.8%) occurred. During follow-up (1174 days), 175 patients died. Using multivariate logistic regression analysis, the significant independent predictors of mid-term death included chronic pulmonary disease (hazard ratio, 2.00, 95% confidence interval, 1.41-2.84; P < .001), peripheral vascular disease (hazard ratio, 1.58; 95% confidence interval, 1.05-2.37; P = .029), and atrial fibrillation (hazard ratio, 1.75; 95% confidence interval, 1.16-2.65; P = .008).
  
  
  CONCLUSIONS
  SAVR in moderate-risk patients is currently performed with one half of the early predicted risk (2.8%) and a low likelihood of complications, including a 1.8% incidence of stroke. Patients counseled for randomization to transcatheter aortic valve insertion should be informed of the excellent early to mid-term outcomes of SAVR, particularly those without pulmonary impairment, peripheral vascular disease, or atrial fibrillation.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Sebastian A
authors.initials: SA
authors.lastname: Iturra
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address: suri.rakesh@mayo.edu.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Greason
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: John M
authors.initials: JM
authors.lastname: Stulak
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Harold M
authors.initials: HM
authors.lastname: Burkhart
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001281:Atrial Fibrillation / Q000453:epidemiology; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000401:mortality; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000009:adverse effects; D005260:Female; D006333:Heart Failure / Q000453:epidemiology; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D016015:Logistic Models; D008171:Lung Diseases / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D016491:Peripheral Vascular Diseases / Q000453:epidemiology; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D057212:Therapeutic Equipoise; D013997:Time Factors; D016896:Treatment Outcome
keywords: 28.1; 35.2; AS; AVR; CABG; EuroSCORE; European System for Cardiac Operative Risk Evaluation; PROM; SAVR; STS; Society of Thoracic Surgeons; TAVR; aortic stenosis; aortic valve replacement; coronary artery bypass grafting; predicted risk of mortality; surgical aortic valve replacement; transcatheter aortic valve implantation